Hepatic artery variants:

  • R hepatic artery: off of SMA in 20%

  • L hepatic artery: off of L gastric artery in 10%

Kupffer cells: Liver Macrophages, clear portal blood immune-surveillance

Portal vein: SMV + splenic vein. (IMV joins splenic 1st)

  • Portal system has no valves

Portal triad:

  • Portal vein posteriorly; CBD on R (laterally) and Hepatic artery on L (medially)

  • All elements meet at the Hepatoduodenal ligament

  • Enters segments IV and V of the liver
  • Gall bladder lies under segments IV & V

Hepatorenal syndrome:

  • See low urinary Na

  • Similar appearance as prerenal azotemia
  • Tx: Stop diuretics; give volume.

Portal hypertension:

  • Normal PV pressure: < 12 mmHg
  • Coronary Veins: act as collaterals between portal vein and the systemic venous system of the lower esophagus

  • Surgical Shunts:
    • Child’s B or C = TIPS
    • Child’s A w/just bleeding as symptom= consider splenorenal shunt

Splenic Vein Thrombosis = Most often caused by pancreatitis = Isolated gastric varices

  • Tx: Splenectomy

Amebic abscess: (anchovy paste)

  • MC in right lobe, often single
  • Reaches liver via portal vein
  • Tx: metronidazole, not surgical

Hydatid = Echinococcal cyst:

  • (+) Casoni skin test
  • (+) Indirect hemagglutination
  • CT shows calcified ectocyst and endocyst
  • Do not aspirate: can cause anaphylactic shock
  • Resect (pericystectomy) Need to get all cyst wall

Hepatic adenoma:

  • Woman, OCPs, steroids, type I collagen storage disease
  • 10-20% rupture/bleed
  • Have malignant potential
  • Dx: 'Cold’ on liver scan (no sulfur colloid uptake) No kupffer cells in adenomas
  • Tx: Hepatic adenoma is an indication for resection if symptomatic

Focal nodular hyperplasia:

  • Has central stellate scar
  • No malignant risk
  • Does not rupture
  • Dx: Has kupffer cells so will take up sulfur colloid on liver scan
  • Tx: Conservative

Hepatic hemangioma:

  • MC benign hepatic tumor
  • Rupture rarely, most asymptomatic, more common in women.
  • Dx: Avoid Bx = Risk of bleed
    • ​CT= Peripheral to central enhancement
  • ​Tx: Do nothing unless giant or symptomatic/consumptive = Surgery +/- embolization, XRT & steroids if unresectable
  • Kasaback Merritt syndrome: consumptive coagulopathy or CHF due to hemangioma.

Hepatocellular CA: is #1 CA worldwide.

  • Alpha-FP correlates w/ tumor size
  • Chronic Hep B #1 cause world wide
  • Also associated w/ EtOH, hemochromatosis, primary sclerosing cholangitis, alpha-1 antitrypsin deficiency, clonorchis sinensis (flukes), aflatoxin, hepatic adenoma, steroids, pesticides
  • Fibrolamellar variant, lymphocyte infiltrative and clear cell have better Prognosis.
  • Work up of a cirrhotic patient with a liver lesion should include:
  • Hep B and C Antibodies panel
  • LFTS (although nonspecific)
  • Alpha-Feto Protein (AFP) (elevated in approximately 80% of cases)
  • Imaging:
    • ​Right Upper Quadrant Ultrasound
    • CT-scan
    • MRI if needed to determine resectability.
  • The hepatic arteries supply metastatic and primary tumors of the liver
  • Primary liver tumors = Hypervascular
  • Metastatic liver tumors = Hypovascular

Gallbladder: has no submucosa

Gallbladder concentrates bile:

  • By active absorption of NaCl (H2O then follows)

Sphincter of Oddi:

  • Morphine: Contracts
  • Glucagon: Relaxes

Most common organism in cholecystitis: E. Coli, klebsiella, enterococcus

Cholecystitis US findings: Gallstones

  • Gallbladder wall thickening (>4mm)
  • Pericholecystic fluid
  • Dilated CBD (.8mm) suggests CBD stone obstruction

Indications for pre-op ERCP: signs that common bile duct stone is present

Retained CBD stone Identified on T-tube cholangiogram 6 weeks postop best managed by radiology stone retrieval

Bacterial infection of bile: dissemination comes from portal vein system.

Intra Vs. Extrahepatic cholestasis: The absence of dilated pancreatic and biliary ducts suggests intrahepatic cholestasis.

Acalculous cholecystitis:

  • Thickened wall, RUQ pain, éWBC
  • Common after: burns, TPN, trauma, major surgery
  • Due to Bile stasis; éviscosity secondary to dehydration, ileus, transfusions
  • Normal GB EF > 35%
  • Dx: HIDA = If <35% EF of gallbladder volume excreted after CCK over 2 hours è Means Bilary dyskinesia
  • Tx: Cholecystectomy
  • (Surgeons typically label acalculous cholecystopathy as biliary dyskinesia. For gastroenterologists, biliary dyskinesia is a synonym for sphincter of Oddi dysfunction, which is a distinct disease process)

Enphysematous gallbladder disease:

  • édiabetics secondary to clostridium perfringens

Gallstone Ileus: MC site of obstruction = Terminal ileum


  • Jaundice + RUQ tenderness + Fever (Charcots Triad)
  • + Hypotension + Change in mental status (Renol Pentad)
  • Tx: Needs immediate IV abx, fluid resuscitation and emergent drainage of CBD- ERCP/PTC or Surgery.

Benign biliary stricture: #1 cause is iatrogenic (lap chole)

Hematobilia triad:

  • GI bleed + Jaundice + RUQ pain.
  • Workup (and Tx) with arteriogram/embolization

Porcelain gallbladder:

  • 30-65% risk of cancer
  • Cholecystectomy indicated.

Gallbladder adenocarcinoma:

  • More common than bile duct cancer
  • 90% have stones
  • Cholecystectomy adequate if confined to mucosa
  • If grossly visible tumor:
  • Regional lymphadenectomy
  • Wedge segment V
  • Skeletonize portal triad.

All items (1)